1205940210 NPI number — DR. BRADFORD BENTON PERRY M.D.

Table of content: (NPI 1255416616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205940210 NPI number — DR. BRADFORD BENTON PERRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRY
Provider First Name:
BRADFORD
Provider Middle Name:
BENTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205940210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 CENTRAL AVENUE
Provider Second Line Business Mailing Address:
SUITE 214
Provider Business Mailing Address City Name:
SCARSDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10583-1102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-472-2167
Provider Business Mailing Address Fax Number:
914-472-2097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 CENTRAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 214
Provider Business Practice Location Address City Name:
SCARSDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10583-1102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-472-2167
Provider Business Practice Location Address Fax Number:
914-472-2097
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  162803 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01064020 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P558687 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 109817 . This is a "MHN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 147571 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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